Surgery for Aortic
Dissection
Adrian E. Manapat, M.D.
Mortality of Aortic Dissection
Acute aortic dissection
Lindsay, Hurst (1967) :
33% within 24 hrs
50% within 48 hrs
80% within 7 days
95% within 1 month
for Type B 25% at 1 month
Acute/Chronic/A/B
Anagnostopoulos (1972) 70% at 1 week
90% at 3 months
Management of acute aortic
dissection
Type A dissection Surgical repair
(Modes of exit: Cardiac tamponade
MI
Heart failure from AI
Stroke)
Type B dissection Medical > Surgical
Risk of cardiac tamponade 2%
Stanford Duke Collaborative
Study
80
70
60
50
40
Medical
Surgical
30
20
10
0
Life
Other medical Low risk, open
threatening
problems
choice
complications
Management of Type B
dissection
Indications for surgery
1. Life threatening complications of dissection
a) Aortic rupture/leak
b) Infarction/ischemia of major end organ (kidneys,
abdominal viscera, extremities)
2) Progression of dissection during medical treatment
Indications for medical management
1) Elderly
2) Coexisting serious medical problem - cardiac, pulmonary, renal ,
peripheral or cerebrovascular
3) Thrombosed false lumen
4) Primary tear in distal aorta or abdominal aorta
Craig Miller, 1992
Principles of repair
 Complete obliteration of the tear of the
ascending aorta
 Obliteration of the false lumen
 Prevention of rupture of the jeopardized
segment
 Correction of aortic regurgitation if present
What is so difficult about repair of
aortic dissection?
 Weakened friable aorta does not tolerate
clamping - requires “no touch technique”
 Need for deep hypothermic circulatory arrest
Prolonged complex operation
Almost all of them bleed
Potential for multiple organ damage
Possible catastrophic complications
 Emergency nature
Deep hypothermic circulatory
arrest (DHCA)
 Every 10 o decrease in T causes a 50%
decrease in metabolic rate - protects the organs
from the effects of circulatory arrest
 Safe period CA is usually 45 minutes
 Disadvantages:
prolonged surgery
bleeding
potential for end organ
damage
Cerebral protection during
circulatory arrest
Cerebral perfusion
 Antegrade perfusion via carotid arteries
 Retrograde perfusion via superior vena cava
Adjunctive measures:
 Head packed in ice
 Mannitol, steroids
 Sodium pentothal
 Trendelenberg position
Surgical options
 Supracoronary AA replacement
 Bentall procedure (composite ascending aorta
& aortic valve replacement w/ re-implantation
of coronary ostia)
 Supracoronary AA replacemnt w/ aortic valve
repair or replacement
 Any of the above combined with CABG
Ascending aortic dissection
False and true lumen
Dealing with the aortic valve
Resuspension of the
commissures to repair
the aortic valve
Insertion of a valved
conduit
Proximal graft anastomosis
completed
Aortic graft in place
Ascending aortic replacement
with CABG
Results of Surgical repair
Operative (30-day) mortality
1960’s 30-60%
1990’s to the present 5-30%
Cleveland Clinic experience (208) predictors of mortality:
Earlier operative year
Hypotension
Non-use of DHCA
Composite valve graft
CABG
Late survival (Crawford, 1990)
1 year 78%
5 years 63%
10 years 55%
Acute type A 5 yrs 56%
10 yrs 46%
20 yrs 30%
Long term follow up
 Lifelong antihypertensive, B blocker
 Anticoagulation for prosthetic valve
 Surveillance :
new dissections
aneurysm formation
prosthetic valve function